This document provides guidance on assessing and managing critically ill children presenting to the emergency department. It outlines the Pediatric Assessment Triangle (PAT) as a rapid and effective initial evaluation tool focusing on appearance, work of breathing, and circulation. The PAT evaluates tone, interaction, consolability, gaze and cry to assess appearance while circulation is determined by heart rate, capillary refill time, pulses, skin color and temperature. It emphasizes treating the child rather than the diagnosis and remembering key physiological differences between adults and children.

2. RECOGNITION OF THE
CRITICALLY ILL CHILD
PAEDIATRIC ASSESSMENT
TRIAGE:

3. How to do rapid and accurate evaluation of cases in
ED to determine critically ill cases.
 Know the three components of the Pediatric
Assessment Triangle
Have systematic approach to sick child in ED
 Know the ED management of Common Pediatric
Emergencies
OBJECTIVES AND GOALS:

4. oChildren are not young adults
oAdults are big children but with chest pain
o Different age group
oAge specific norms
o Remember important differences between adult and
kids
REMEMBER THAT:

5. ILL CHILD COME TO ED
HOW TO DEAL??
ABCDE ASSESSMENT
VITAL SIGNS,DETAILED HISTORY,PHYISCAL
EXAM

6. PAEDIATRIC ASSESSMENT TRIANGLE

7. It is a rapid, accurate and easily-
learned model for the initial
assessment of any child
It allows the clinician, using only
visual clues, to rapidly assess the
severity of the child’s illness or
injury and urgency for treatment,
regardless of the underlying
diagnosis.
???WHAT IS PAT

8. door step” assessment.
 “PAT” is the tool.
 Some idea about – Respiratory /
Circulatory /Neurological.
 No touching baby
No stethoscope
 No pricking / intervention.
PAT IS THE INITIAL STEP:

10. Reflect the adequacy of :
Oxygenation
Ventilation
Brain perfusion
Cns function
APPEARANCE

11.  MNEMONIC – TICLS
 Tone
 Interactiveness
 Consolability (overlaps with
irritability)
 Look / Gaze (“glassy eyed”
 Speech / Cry (high pitched, ‘cephalic’)
 Level of alertness, somnolent, lethargic
STAND BACK!!! - APPEARANCE

12. MUSCLE TONE

13. INTERACTIVNESS,LOOK,GAZE,SPEECH,
CRY
ALERT
EYE
CONTACT
Inconsonable
crying

15. • All of the above normal suggests at
least adequate ventilation, oxygenation
and brain perfusion
• Ask the parents!!! What is normal?
• Watching interaction with parent can
differentiate behaviour from illness
• Inconsolable versus irritable
• More difficult the younger the patient
(Neonates can ‘startle’ and cry)
:NORMAL

16. Corneal ulcer
Testicular torsion
Meningitis
colic and constipation
TRULY “INCONSOLABLE” CHILDREN

17. •Is the child breathing?
•Is there central cyanosis?
•Does the child have severe respiratory
distress?
Airway & Breathing - assessment

18. IS THE CHILD BREATHING?
•Look: If active, talking, or crying, the child is obviously
breathing. If none of these, look again to see whether
the chest is moving.
•Listen: Listen for any breath sounds.
•Feel: Feel the breath at the nose or mouth of the child.
Gasping is spasmodic open mouth breathing associated
with sudden contraction of diaphragm & retraction of
hyoid apparatus. It is a manifestation of brain hypoxia.

19. IS THERE CENTRAL CYANOSIS?
•To assess for central cyanosis, look at the mouth and
tongue.
•A bluish or purplish discoloration of the tongue and the
inside of the mouth indicates central cyanosis.

20. DOES THE CHILD HAVE SEVERE
RESPIRATORY DISTRESS?
•Respiratory rate ≥ 70/min
•Severe lower chest in-drawing
•Head nodding
•Apneic spells
•Unable to feed due to respiratory problem
•Stridor (A harsh noise on breathing in is called stridor.(
•Grunting (A short noise when breathing out in young infants
is called grunting.(

21. Airway management
•Manage airway
•Provide BLS - Basic Life Support
•Give Oxygen
•Make sure child is warm
Airway & Breathing - management

22. •If there is history of foreign body aspiration or if the
child is choking with increasing respiratory distress,
suspect foreign body.
•Clear any secretions in present.
Airway management

23. MANAGEMENT OF CHOKING IN YOUNG
INFANT
 Lay the infant on arm or thigh in a head
down position.
 Give 5 blows to the infant’s back with heel of
hand. (Back slaps(
 If obstruction persists, turn infant over and
give 5 chest thrusts with 2 fingers, one
finger breadth below nipple level in midline.
(Chest thursts(
 If obstruction persists, check infant’s mouth
for any obstruction which can be removed.
 If necessary, repeat sequence with back
slaps again.

24. MANAGEMENT OF CHOKING IN OLDER CHILD
 Give 5 blows to the child’s back with heel of hand with
child sitting, kneeling or lying. (Back slaps(
 If the obstruction persists, go behind the child and pass
your arms around the child’s body; form a fist with one
hand immediately below the child’s sternum; place the
other hand over the fist and pull upwards into the
abdomen; repeat this Heimlich maneuver 5 times.
 If the obstruction persists, check the child’s mouth for
any obstruction which can be removed.
 If necessary, repeat this sequence with back slaps
again.

25. NECK TRAUMA
Suspect when there is history of trauma to head and neck region or history
of fall or external injuries to head and neck region on examination.
•Keep the child lying on the back
on a flat surface.
•Tape the child’s forehead to the
sides of a firm board to secure
this position.
•Prevent the neck from moving by
supporting the child’s head.
•Place a strap over the chin.

26. OPENING THE AIRWAY IN AN INFANT & OLDER
CHILD

27. oGoals
Adequate cardiovascular function and tissue perfusion
Effective circulating fluid volume
Normal core body temperature
oReflect adequacy of
Cardiac output
Perfusion of vital organs
CIRCULATION:

28.  Circulation assessed by evaluation of
• Heart rate and rhythm
• Pulse
• Capillary refill time
• Skin color and temp
• Blood pressure
CIRCULATION:

29. Cardiovascular signs

30. 1-HEART RATE
• HR with age
• In cardiac arrest
Early HR
Late HR
• Normal HR in presence of other signs of circulatory
insufficiency is a bad prognostic sign

31. Age (years( HR
>1 110-160
1-2 100-150
2-5 95-140
5-12 80-120
<12 60-100

32.  Time takes for blood to return to
tissue blanched by pressure.
 Increase as skin perfusion decrease.
 Prolonged CFT(3-5seconds) indicate
low cardiac out put.
Normal CFT <= 2
To evaluate CFT lift extremity slightly
above the level of the heart, press on
the skin and rapidly release the
pressure
2-CAPILLARY REFILL TIME

34. Grade Description
+4 Full , NOT obliterated with pressure
+3 Normal easily palpated NOT easily obliterated with pressure
+2 Difficult to palpate obliterated with pressure
+1 Thready and weak difficult to palpate
0 Absent
3-PULSE VOLUME
 Compare strength and quality of central
and peripheral pulses
 Central pulse
infant > brachial or femoral
old child >carotid artery

35. 4-BLOOD PRESSURE
Age (years( SBP (mmHg(
>1 70-90
1-2 80-95
2-5 80-100
5-12 90-110
<12 100-120
BP with age
<2Y SBP =70+(2 X age in
years(
Hypotension is a late and pre
terminal sign
Absence of hypotension NOT
exclude shock

36.  Mucous membrane, nail beds, palms and soles
should be pink.
 When perfusion deteriorates and O2 delivery to
tissue becomes inadequate the hands and feet
are typically affected 1st.
 They may become cool , pale, dusky or mottled.
 If perfusion become worst skin over the trunk
and extremities may under go similar changes
5-SKIN AND TEMPERATURE

37. Pallor
mottled

38.  Respiratory system
tachypnea without recession
 Skin
mottled ,cold ,pale
 Mental
irritable then unresponsive
 Urinary output
UOP less than 1ml/kg/h in child indicate
inadequate renal perfusion
EFFECTS OF CIRCULATORY INADEQUACY ON
OTHER ORGANS

39. THERE IS A CLEAR OVERLAP BETWEEN
RESPIRATORY AND CIRCULATORY FAILUER

40. 1. Cyanosis despite supplied
oxygen
2. Quite tachypnea (tachypnea
without recession)
3. Raised jugular venous
pressure
4. Gallop rhythm / murmur
5. Enlarged liver
THE FOLLOWING SIGN ARE MORE IN FAVOR OF
A CIRCULATORY CONDITION

41. oQuick neurological examination:
o consciousness level:
DISABILITY

43. The posture at rest/without stimulation may be abnormal. For
example the seriously ill child may be hypotonic (floppy),a painful
stimulus should be then applied. This may elicit abnormal stiff
posturing:
Decorticate (flexed arms and extended legs)
Decerebrate (extended arms and legs).
POSTURE

44. When examining the pupils note the size, equality and reaction to light.
A fixed dilated pupil in the context of a brain injury indicates herniation of
the temporal lobe through the tentorial hiatus (‘coning’) as a result of 3rd
cranial nerve compression. Urgent discussion with a neurosurgical centre
is required.
Bilateral fixed dilated pupils are a sign of brain death but can occur in
hypothermia, severe hypoxia, during and post seizure, anticholinergic
overdose and in deep unconsciousness.
Small reactive pupils can be seen in metabolic disorders.
Pinpoint pupils are seen with an opioid overdose and organophosphate
ingestion.
PUPILS

45. Tone
Interactivity (mental status)
Consolablity by parents
Look or Gaze
Speech or Cry
Abnormal reflexs
Motor activity
Eye contact (>2 months)
OTHER NEUROLOGICAL SIGNS

46. Both hypo and hyperglycemia can cause a change in level or
consciousness and neurological functioning. The blood
glucose should be measured as part of your assessment of D.
A rapid finger-prick bedside testing method can be used.
BLOOD GLUCOSE

47. Category Assessment Actions Example
Critical Absent airway,
breathing, or
circulation
Perform rapid initial
interventions and transport
simultaneously
Severe traumatic injury
with respiratory arrest or
cardiac arrest
Unstable Compromised airway,
breathing, or
circulation with
altered mental status
Perform rapid initial
interventions and transport
simultaneously
Significant injury with
respiratory distress,
active bleeding, shock;
near-drowning;
unresponsiveness
Potentially
unstable
Normal airway,
breathing, circulation,
and mental status BUT
significant mechanism
of injury or illness
Perform initial assessment
with interventions; transport
promptly; do focused history
and physical exam during
transport if time allows
Minor fractures;
pedestrian struck by car
but with good appearance
and normal initial
assessment; infant
younger than three
months with fever
Stable Normal airway,
breathing, circulation,
and mental status; no
significant mechanism
of injury or illness
Perform initial assessment
with interventions; do
focused history and detailed
physical exam; routine
transport
Small lacerations,
abrasions, or
ecchymoses; infant older
than three months with
fever
PEDIATRIC CUPS ASSESSMENT

48. CARDIOPULMONRY ARREST

50. 1) Hypoxia
2) Hypotension
3) Hypothermia
4) Hypoglycemia
5) Acidosis (H+)
6) Hypokalemia (electrolyte disturbance)
7) Cardiac Tamponade
8) Tension pneumothorax
9) Thromboembolism (pulmonary, coronary)
10) Toxicity (eg. digoxin, local anesthetics, TCA, insecticides).
CAUSES OF CARDIOPULMONRY ARREST

51. RESPIRATORY CARDIAC ARREST TREATMENT
Infant
>1year
Child
1-8years
Teen
9-18years
Ventilation 20/min 20/min 12/min
CPR method 2finger 1hand 2hand
Chest depth 1/3-1/2 1/3-1/2 1/3-1/2
Compression rate
ratio
≤100/min
5:1
≤100/min
5:1
≤100/min
5:1
CPR should be started for HR>60.
Only AEDs with pediatric capabilities should be
used on patients > 8 yrs. of age (approx. 25kg
or 55lb).